Nose Art


Ed: You say no nasal, I cut my nose right off, take my septum leave it behind the couch
Voice: You leave your septum right where its sittin'
Ed: That's right, I leave it in the tank at home .... the septum tank.        --Hamell On Trial


 

Functional Endoscopic Sinus Surgery

Why?

Recently, I went through the process of sinus surgery to, hopefully, lessen my disabling fatigue, and frequent "cold like" symptoms which after several years, have become more and more chronic. It look quite a bit of persistence to narrow it down to sinusitis, and I wanted to share what I know about sinuses and some of my experience with the surgery operation used to clear things up. Am writing this up to document the process and hopefully help others in the same predicament. But first a bit of background on the sinuses and "FESS".

Background and overview

The last few decades have really made great leaps and bounds regarding sinus surgery procedures. Now most of the corrective surgical options can be done via small little cable cameras and cable instruments inserted via the nose. This process is called FESS - or Functional Endoscopic Surgery (Wikipedia). To be clear, FESS is a process or technique used in sinus surgery but doesn't necessary imply what areas of correction will need to be pursued - some of those will be covered later. For the area of correction to be determined, your sinus doctor will use a endoscope "remote camera" inserted via the nose to look around and see what the issues might be if any. Additionally, usually a CT scan will be ordered so to give a detailed look into the sinuses.

Sinus CT Scan

A CT scan is much like an x-ray, the only major difference is that the actual scanning process is done in very narrow layers or slices - typically starting from the tip of you nose and working straight back into your head. Above is a single slice of my sinus CT scan showing several of the major sinus/nose areas. This single slice scan (shown twice) was done when my sinuses were relatively healthy. The light blue color is my septum, the center dividing line going down the center of my nose. The two big round uncolored areas are my eye sockets. From there you have the maxillary/cheek sinuses in red, turbinate in yellow, and ethmoid sinuses in green. Frontal and sphenoid sinuses cannot be seen since they do not appear on this slice - as they are at different depths.

FESS surgery typically involves up to six areas of correction depending on your sinus makeup and symptoms. Its like a surgical buffet:

  • Open drainage ducts of the frontal sinus.

  • Open ethmoid sinuses and remove infected tissue (green area in CT scan). The Ethmoid sinuses have lots of small bony partitions subdividing them. This routine typically removes all these fine partitions - opening them up to drain better.

  • Open up maxillarary sinuses (red area in CT scan) to allow for better drainage and remove infected tissue.

  • Open up sphenoid sinuses and remove infected tissue

  • Trim turbinates to allow for clearer breathing (yellow area in CT scan)

  • Straighten a deviated septum ( a procedure known as septoplasty - blue area in CT scan)
  • Turbinate DiagramCertainly not all these are done every time. Although in my case, I had all of them done - with focus on the maxillary and ethmoid sinuses. Bizarrely, although this CT scan shows a pretty straight septum, the later scans and phyiscal inspection showed it being notably "deviated". Not sure when that happened!

    On the right - I'm including one diagram I found on MedLine that shows the turbinates quite clearly. I've done quite a bit of searching and had a hard time finding a diagram that really helped me understand how they fit .... so perhaps this helps. The pointer to "inflamed membranes" are the upper and lower turbinates seen above in blue.

     

    Diagnosis

    Well I suppose I should step back before going into the procedure and mention that sometimes being diagnosed with having chronic sinus issues can be trickier than expected. CT scans are quite amazing technology, however they don't necessarily show the doctor everything that is going on and thus can be somewhat misleading. Additionally, they are an exact snapshot in time. Sinus conditions can change with the days so sometimes conditions don't appear on the scans as clearly as they perhaps should.

    My doctor/surgeon tried many drug therapies to see if we could eliminate the condition without having to go thru the more drastic action of surgery. Several rounds of antibiotics and corticosteroids were tried over the course of nearly a year - and while they helped me, the affect was fairly short lived at a month or so.

    This was getting very frustrating - since being eternally sick feeling and exhausted - for months at a time is simply no fun. Finally we ran out of options - and surgery was suggested.

    Going under the knife endoscope

    As surgery goes, FESS is fairly minor surgery when compared to open heart surgery or a routine of that magnitude. In fact I was told that I'd could be back to work in 5-7 days and to not fly or do anything too athletic for a couple weeks. Certainly that can be the case - but based on my experience - plan on at least a couple weeks of at home healing time. Notably, the first week being very miserable - especially if you have any turbinate or septum work done as they tend to be the more "drastic" of the surgery options on the buffet of choices above.

    FESS is an outpatient procedure, meaning that there is no real risk for needing to be on life support or needing constant nurse oversight. However, this is not fun surgery at all - and you will likely go through many of the steps a surgery requiring hospitalization will require.

    Day of surgery

    I reported to the Northwestern Ambulatory surgical center bright and early in the morning. And within an hour, I was denuded into a stylingly lovely hospital gown and my hand had been IV'ed already. Met with the surgeon briefly and then they spiked my IV with some "anti-anxiety" juice or some such thing before I was wheeled into surgery.

    This was no small operating room, people were buzzing around and there were many monitors and such all around me. And then without any warning I was out.

    Based on the CT scans, my doctor said it should be about an hour long surgery. However once he was fully up my nose, it turns out my sinuses were in far far worse shape than he could see on the CT scans. Bad enough that the single hour surgery took two additional hours to perform. Yes three full hours, of cutting and slicing tools (yes power tools) being shoved up my nose and then goop and bone being suctioned out.

    Finally I came to again - with an ice pack over my eyes, nose, and cheek - and a dressing placed under my nose - taped to my face. Within about 20-30 minutes my head really really started hurting - so they upped my pain dose in my IV. The ice pack and IV was removed.

    Once I could eat (jello) and pee, they released me with a script for antibiotics and a opiate-based painkiller. I guess Jello and Pee are the hallmarks of a healthy person! Heh.

    It was now late afternoon.

    First week post surgery

    My Gause MostacheThat first night was wildly unpleasant. First of all, I was told they "don't use packing anymore" so the discomfort is way less than in years past. And while this is true, after surgery I still had several foreign things sutured into my nose to allow things to heal properly. So I was not going to be breathing through my nose for an entire week.

    At all.

    On the surface that doesn't sound so bad, however, once you experience it, you start to realize how damned handy your nose is. Pinch your nose shut and try to eat and (most importantly) swallow. Or talk. Or sleep with your mouth open. Yes, after awhile it starts to feel like drowning, and there is a tenancy to panic at times. Its pretty creepy - but its essential for healing. My understanding is that most of this nasal congestion is from the septoplasty and the turbinate work.

    And then there is the blood. Lots of it leaking out of your nose as it heals. Hence the gauze "moustache" taped to the bottom my nose. For the first few days it would be replaced every 3-4 hours or so since it was fully soaked. But later on in the week I was down to daily replacements. Didn't feel much better, but at least the volume of blood reduced.

    Other things I experienced in the first week. Pain. Yup, that's par for the course with surgery. Aching all over, pain on the upper teeth, pain in the nose, etc etc. Mercifully the painkiller really helped. Opiate-based painkillers make you kinda woosy and sleepy so don't plan on being very "with it" at all when taking them. This also means you need help from others on a semi-regular basis - since lord knows I was pretty out of it. This bears remembering....and repeating. :-D

    The last main symptom of surgery was a fever. Nothing too major but every night I had a roughly 100-101F temperature with the chills and such. Was a bit hard to know for sure since you of course can't breathe AT ALL when taking your temp. Nonetheless, this infection would end up lingering far longer than expected.

    No doubt, surviving without family or close friends helping out and watching over me would have been nearly impossible. Between the side effects of the anestesia, lack of sleep, fever, difficulty eating, overall weakness, and the painkiller "high", I existed, but certainly not without considerable help.

    Week two

    Norco PillsWeek two began with a follow up visit with the surgeon. I still needed my gauze mustache, although it was pretty good by this point. The doctor was somewhat surprised I still needed it - but it seemed rude to drip blood! ;-D

    This first visit was quite the experience - since this is the visit that they removed all the "stuff" that was sutured into my nose during surgery. No doubt about it - it was wildly uncomfortable and hurt. I so wished I had taken some of my Norco before this visit - and was a bit pissed with my doctor for not leveling with me on what this visit would entail. Of course, my doctor seems to be of the philosophy that if he tells you this will hurt, then you will freak out more. He was quick and did really try to watch me to make sure I was ok, but it was on of the more unpleasant things I've experienced. And since my nose was 100% plugged - they couldn't numb it up before the routine. So after the seriously large rolled up soft plastic sheets were removed - they then suctioned out my nose and areas where the sinuses drain.

    Ten minutes later, I was white as a sheet and sweating profusely - and I don't really sweat.

    On the plus side, I could breathe again through my nose. It was raw and tender no doubt, but I could breathe again! Yippie. This was a big juncture in my recovery. I also didn't need the nose gauze anymore - the bleeding had stopped.

    GrossNow that my nose was unjammed of surgical stuff, I had a new job to do to promote healing and rid my body of nasties. That means nasal irrigation.

    There are many ways to do this but I found the Grossan Tip (see picture) attached to a WaterPik filled with saline solution did wonders for pumping out some seriously nasty looking stuff. The saline sinus rinse formulation I used is as follows:

  • 1000mL(~4 cups) of just barely warm water in the WaterPik tank
  • 1 teaspoon of baking powder
  • 2 teaspoons of coarse non-iodized kosher sea salt. Look for the salt with the least caking agents and additives

    It feels odd at first but feels good after awhile. And certainly feel much more open and clear after each rinse. Netti Pots and squeeze bottles from the local pharmacy can also be used, but this combination seemed to work the best for me.
  • But with the good - came some bad. My fever spiked hugely that night and I was a such a shivering mess. Nearly a 102F fever and Tylenol really doesn't do much for it. (Can't take anything that can thin your blood pre or post op - so Ibuprofen and Aspirin are out) I'm guessing with all the suctioning and "stuff" removing, disturbed the remaining nasty bacteria/virii still up in my head - and they went to town on the new raw tissues now that everything got disturbed.

    Slowly things started to improve throughout the week - and I had another major temperature spike the night I came off the antibiotics. As the week rolled on, it still seemed I couldn't knock this fever. It would ebb and flow but just not go away. And I was still quite drained.

    Back to the doctor.

    Infection Complication

    So they grabbed the endoscope and took a looksie. Apparently I had a sinus infection. And I thought that's precisely what this surgery was supposed to correct! Well it is, but only after I heal and the swelling goes down. While most people don't get a sinus infection post-op, it does sometimes happen. And my sinusitis pre surgery was quite extreme. So they put me on a corticosteroid and very powerful antibiotic.

    Week Three and beyond...

    The third week was one of notable improvement. Largely due to the steroid and antibiotic hybrid - but I'll take it. Went back to work. Still found myself wanting to sleep 9-10+ hrs most nights and was starting to eat like crazy. Turns out I'd lost some weight, roughly 5%, over the last few weeks, and I guess the ravenous appetite was to catch up on that. Also found out that most of my muscles were notably weak and ached easily. Apparently they atrophied some during the time. My body needed to metabolize something after all. Wow, for "minor surgery", this really took its toll.

    By week four, life was returning to normal. The WaterPik nasal irrigation was yielding day by day less and less foul black gunk and more healthy(ish) yellow mucus. This is naturally a very good thing. My nose nearly feels normal too - although I'd certainly not want to bump it too hard just yet!

    Conclusion

    Perhaps after reading this, if you are thinking about having an Endoscopic Sinus procedure, you'll have a better idea what you might be in for - and how to prepare.

    If you have questions or comments I'd love to hear from you! E-mail is in the sidebar on the left, upwards.